What are the prospects for meaningful reform of U.S. health care? To answer this question requires understanding why previous reform efforts (and in particular the 1993 Clinton health plan) failed—the combination of deep structural biases against large-scale public provision and the inherited constraints posed by the rise of employment-based insurance. Generally, the context is more favorable today than it was fifteen years ago. But the prospects for change hinge on learning the right lesson of history: Politics comes first. Putting politics first means avoiding the overarching mistake of the Clinton reformers: envisioning a grand policy compromise rather than hammering out a real political compromise. It also means addressing the inevitable fears of those who believe they are well protected by our eroding employment-based framework. And it means premising political strategies on the contemporary realities of hyperpolarized politics, rather than wistfully recalled images of the bipartisan politics of old.
Max J. Skidmore , "Ronald Reagan and `Operation Coffeecup': A Hidden Episode in American Political History,"Journal of American Culture12, no. 3 (1989): 89-96.
2.
See James Farr, Jacob S. Hacker, and Nicole Kazee, "The Policy Scientist of Democracy: The Discipline of Harold Lasswell," American Political Science Review 100, no. 4 (2006): 579-87; and Farr, Hacker, and Kazee, "Revisiting Lasswell," Policy Sciences 41, no. 1 (2008): 21-32.
3.
This section draws on Jacob S. Hacker, "Dismantling the Health Care State? Political Institutions, Public Policies, and the Comparative Politics of Health Reform,"British Journal of Political Science34 (2004): 693-724.
4.
Joseph White, Competing Solutions: American Health Care Proposals and International Experience (Washington, DC: Brookings Institution , 1995).
5.
See Evelyne Huber and John Stephens, Development and Crisis of the Welfare State: Parties and Politics in Global Markets (Chicago: University of Chicago Press, 2001). Using Huber and Stephens's data set (http://www.lisproject.org/publications/welfaredata) and Organization for Economic Cooperation and Development (OECD) expenditure data, the correlation between 1945-75 cumulative left-party governance and the 1975 private share of health spending is -0.58.
6.
In the OECD, only Italy's national health service was not enacted under social democratic rule.
7.
Ellen Immergut, Health Politics: Interests and Institutions in Western Europe ( New York: Cambridge University Press, 1992).
8.
See, for example, Sven Steinmo and Jon Watts, "It's the Institutions, Stupid! Why Comprehensive National Health Insurance Always Fails in America,"Journal of Health Politics, Policy and Law20, no. 2 (1995): 329-72.
9.
Jacob S. Hacker, "The Historical Logic of National Health Insurance: Structure and Sequence in the Development of British, Canadian, and U.S. Medical Policy,"Studies in American Political Development12, no. 2 (Spring 1998): 57-130.
10.
Paul Pierson , "Increasing Returns, Path Dependence, and the Study of Politics,"American Political Science Review94 (2000): 251-67.
11.
Jacob S.Hacker, The Divided Welfare State: The Battle over Public and Private Social Benefits in the United States (New York: Cambridge University Press, 2002).
12.
Frank D.Campion, The AMA and U.S. Health Policy since 1940 ( Chicago : Chicago Review Press, 1984), 162.
13.
"Memorandum of the Congress of Industrial Organizations in Support of the Principle that Employer Payments for the Cost of Group Hospitalization Medical and Like Benefits are not Taxable Income to the Employee," Office of Tax Policy, Box 4, National Archives and Records Administration , 1.
14.
Ibid., 19.
15.
Ibid., 22.The 1949 quote is from the testimony of James B. Carey to Subcommittee on Health of the Committee on Labor and Public Welfare, National Health Program, 1949 ( Washington, DC: U.S. GPO, 1949), 421.
16.
Paul Starr toIra Magaziner, March 22, 1993; quoted in Jacob S. Hacker, The Road to Nowhere: The Genesis of President Clinton's Plan for Health Security (Princeton, NJ: Princeton University Press, 1997), 128.
17.
Paul Starr and Walter L. Zelman , "A Bridge to Compromise: Competition Under a Budget,"Health Affairs12, Supplement 1 ( 1993): 7-23.
18.
Robert Patricelli, Chamber of Commerce, to Ira Magaziner, May 10, 1993; quoted in Hacker, The Road to Nowhere: The Genesis of President Clinton's Plan for Health Security (Princeton, NJ: Princeton University Press, 1997), 135.
19.
Walter Zelman to Bob Boorstin, March 10, 1993; quoted in Hacker, Road to Nowhere: The Genesis of President Clinton's Plan for Health Security ( Princeton, NJ: Princeton University Press , 1997), 136.
20.
Consumer Reports, "Health Insurance Survey Reveals 1 in 4 People Insured but Not Adequately Covered," September 2007.
21.
The Kaiser Family Foundation, Employer Health Benefits, 2007Summary of Findings, http://www.kff.org/insurance/7672/upload/Summary-of-Findings-EHBS-2007.pdf; and Jared Bernstein and Heidi Shierholz, "A Decade of Decline: The Erosion of Employer-Provided Health Care in the United States and California, 1995-2006," EPI Briefing Paper 209, April 16, 2008.
22.
The Kaiser Family Foundation, Employer Health Benefits, 2007Summary of Findings, http://www.kff.org/insurance/7672/upload/Summary-of-Findings-EHBS-2007.pdf .
23.
Cristina Boccuti and Marilyn Moon, "Comparing Medicare and Private Insurers: Growth Rates in Spending over Three Decades,"Health Affairs22, no. 2 ( 2003): 230-37.
24.
Gerard F. Anderson, Uwe E. Reinhardt, Peter S. Hussey, and Varduhi Petroysan, "It's the Prices, Stupid: Why the United States Is So Different from Other Countries,"Health Affairs22, no. 3 (2003): 89-105.
25.
McKinsey & Company, "Accounting for the Cost of Health Care in the U.S," January 2007, http://www.mckinsey.com/mgi/reports/pdfs/healthcare/MGI_US_HC_fullreport.pdf.
26.
Karen Davis , Cathy Schoen, Stephen C. Schoenbaum, Michelle M. Doty, Alyssa L. Holmgren, Jennifer L. Kriss, and Katherine K. Shea , "Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care," 59 (The Commonwealth Fund, May 15, 2007).
27.
Ellen Nolte and C. Martin McKee , "Measuring the Health of Nations: Updating an Earlier Analysis,"Health Affairs27, no. 1 (2008): 58-71.
28.
This conclusion has been popularized by Drew Westen, The Political Brain: The Role of Emotion in Deciding the Fate of the Nation ( New York: Public Affairs Books, 2007).
29.
New York Times/CBS News Poll, February 23-27, 2007, http://graphics8.nytimes.com/packages/pdf/national/03022007_poll.pdf.
30.
Jeffrey Jones, "Low Trust in Federal Government Rivals Watergate Era Levels," Gallup News, September 26, 2007; and Joseph Nye, Philip Zelikow, and David King, eds., Why People Don't Trust Government (Cambridge, MA: Harvard University Press, 1997).
31.
For a good recent compendium of polls, see Ruy Teixeira, "What the Public Really Wants on Health Care," The Century Foundation, December 4, 2006, http://tcf.org/ publications/healthcare/wtprw.healthcare.pdf. See also Kaiser Family Foundation/Harvard School of Public Health, "The Public's Health Care Agenda for the New Congress and Presidential Campaign," December 2006, http://www.kff.org/kaiserpolls/upload/7597. pdf.
32.
Most striking is the increasing liberalism seen in James Stimson's "public mood" series, which uses multiple survey questions asked with the same wording over time to track the liberalism or conservatism of the American public. Stimson's data show that in 2004, the public mood was more liberal than at any point since 1961. Updated from James A. Stimson, Public Opinion in America: Moods, Cycles, and Swings, 2nd ed. (Boulder, CO: Westview, 1999), http://www.unc.edu/~jstimson/time.html .
33.
Ylan Q. Mui and Dale Russakoff, "Wal-Mart, Union Join Forces on Health Care; Alliance's Goal Is to Improve Coverage,"Washington Post, February 8, 2007, D1.
34.
In a February 2007 poll, for example, 64 percent of respondents agreed that "the federal government should guarantee health insurance for all Americans," while 27 percent disagreed. Asked to choose between universal coverage and maintaining recent tax cuts, 76 percent chose universal coverage; 60 percent said they would be willing to pay higher taxes to cover the uninsured. New York Times/CBS News Poll, February 23-27, 2007, http://graphics8.nytimes.com/packages/pdf/national/03022007_poll.pdf .
35.
Cathy Schoen et al., "How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007,"Health Affairs, Web exclusive , June 10, 2008.
36.
According to an August 2007 Gallup poll, 36 percent of employed Americans are "completely" satisfied with the health insurance they receive at their job, and 28 percent are "somewhat" satisfied. Poll conducted August 13 to August 16, 2007, and based on telephone interviews with a national adult sample of 1,019 (USGALLUP.112707.R01B). Available from the Roper Center for Public Opinion Research, University of Connecticut.
37.
Rockefeller Foundation/Time Campaign for American Workers Survey, conducted by Penn, Schoen and Berland Associates, June 19 to June 29, 2008, and based on telephone interviews with a national adult sample of 2,008. Question USPENN .08WORKC.R42, asked of those in survey who reported having insurance. Data available from the Roper Center for Public Opinion Research, University of Connecticut.
38.
These coverage estimates are from the March Current Population Survey and reported in Jacob S. Hacker, "Health Care for America: A Proposal for Guaranteed, Affordable Health Care for All Americans Building on Medicare and Employment-Based Insurance," Economic Policy Institute Briefing Paper no. 180, January 11, 2007, http://www.sharedprosperity.org/bp180.html.
39.
The Lewin Group, "Cost Impact Analysis for the Health Care for America Proposal," February 15, 2008, http://www.sharedprosperity.org/hcfa/lewin.pdf .
40.
Tip O'Neill and Gary Hymel, All Politics Is Local: And Other Rules of the Game (New York: Crown , 1993).
41.
Quoted in Jacob S.Hacker and Paul Pierson, Off Center: The Republican Revolution and the Erosion of American Democracy (New Haven, CT: Yale University Press, 2005), 110.
42.
David R. Mayhew , Divided We Govern: Party Control, Lawmaking, and Investigations, 1946-2002, 2nd ed. ( New Haven, CT: Yale University Press, 2005).
43.
See Hacker and Pierson, Off Center: The Republican Revolution and the Erosion of American Democracy ( New Haven, CT: Yale University Press, 2005).
44.
Thomas Schaller , "Gettysburg, Again,"American Prospect, November 19, 2006.
45.
In December 2007, 65 percent of Americans supported a "universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers."Associated Press-Yahoo Poll, December 14-20, 2007, http://news.yahoo.com/page/election-2008-political-pulse-voter-worries . Even greater enthusiasm can be found for a play-or-pay requirement: Nearly nine of ten Democrats and four of five independents, and even 73 percent of Republicans, express support. Commonwealth Fund Biennial Health Insurance Survey, June to October 2007, http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=647816 .
